Forms

• Best Available Evidence (BAE) - Centers for Medicare and Medicaid Services
• Appointment of Representative Form (PDF) - Centers for Medicare and Medicaid Services. If a member would like to appoint a person to file a grievance, request an organization determination, or request an appeal on his or her behalf. 
• Medicare Complaint Form - Centers for Medicare & Medicaid Services. You may also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048. Calls to these numbers are free.
• Request for Medicare Prescription Drug Coverage Determination Form
• Civil Right Notice and Language Block 

You may also call Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 877-486-2048. Calls to these numbers are free.

IMCare Classic (HMO SNP) is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in IMCare Classic (HMO SNP) depends on contract renewal.

H2417 IMCARECLASSIC_114 CMS_Approved 04/04/2017
​Last Updated_04/05/2017